A 5-year-old child is brought to the emergency department 30 minutes after accidentally pulling a pot of boiling water over himself, sustaining a 15% TBSA scald injury to the right shoulder, chest, and right arm. The child is crying, alert, and has intact peripheral pulses. Vital signs are normal. After initial assessment and pain control, what is the most appropriate next step in management?

Explanation

## Management of Moderate Partial-Thickness Scald Injury in a Child **Key Point:** A 15% TBSA scald injury in a child is a moderate burn requiring referral to a burn center, but does NOT meet criteria for aggressive fluid resuscitation (Parkland formula is indicated for >15% TBSA in children or >20% TBSA in adults). ### TBSA Estimation and Fluid Resuscitation Thresholds | TBSA Range | Adult Threshold | Child Threshold | Fluid Resuscitation? | | --- | --- | --- | --- | | <10% | <10% | <10% | Oral fluids only | | 10–20% | 10–20% | 10–15% | Oral or IV (borderline) | | >20% | >20% | >15% | **Parkland formula required** | | >30% | >30% | >20% | Burn center referral mandatory | **High-Yield:** This child has 15% TBSA — at the threshold. Most guidelines recommend burn center referral for: - **Any deep partial-thickness (2nd degree) or full-thickness (3rd degree) burn** regardless of TBSA - **Partial-thickness burns >10% TBSA in children** (this patient qualifies) - Burns involving face, hands, feet, genitalia, or joints ### Why Clean Dressing + Burn Center Referral Is Correct | Step | Rationale | | --- | --- | | Clean dry dressing | Prevents contamination, reduces pain, maintains moisture balance | | Elevation | Reduces edema and improves perfusion | | Burn center referral | Specialized wound care, infection prevention, optimal healing | | No aggressive IV fluids (yet) | 15% TBSA is borderline; most fluid loss is interstitial, not intravascular | **Clinical Pearl:** Scalds in children are often deep partial-thickness (appear red, blistered, very painful). Even at 15% TBSA, the depth and location (chest, shoulder) warrant specialist evaluation to prevent infection and optimize cosmetic outcomes. ### Why Other Options Are Wrong **Ice water immersion (Option 0):** While cooling within the first 20 minutes is appropriate for minor burns, it is NOT the "next step" after initial assessment. The priority here is wound coverage and specialist referral. Ice water is also contraindicated in large burns (risk of hypothermia) and should be brief (10 min max). **Parkland formula (Option 2):** Not indicated for 15% TBSA in a child. Aggressive IV resuscitation is reserved for >15% TBSA in children. This patient's vital signs are normal, and there is no evidence of hypovolemia. **Escharotomy + grafting (Option 3):** Escharotomy is not indicated (no circumferential burns or respiratory compromise). Skin grafting is a delayed procedure, not an acute intervention. **Mnemonic: SCALD (Moderate burn approach)** — **S**pecialist referral, **C**lean dressing, **A**ssess depth/location, **L**ift (elevate), **D**elay aggressive fluids (if <15% TBSA in child)